Medical Policy

 

Subject: Peripheral Bone Mineral Density Measurement
Document #: RAD.00004 Publish Date:    06/28/2018
Status: Reviewed Last Review Date:    11/02/2017

Description/Scope

This document addresses peripheral bone density studies including the use of heel densitometry, peripheral dual energy x-ray absorptiometry (pDEXA), radiographic absorptiometry of the fingers, single energy X-ray absorptiometry (SEXA), single photon absorptiometry (SPA), and dual X-ray and laser (DXL).

Bone mineral density (BMD) measurement is a non-invasive technique that is used to measure bone mineral content and bone mineral density. Its primary role is to detect osteoporosis and to predict the risk of fractures. Dual-energy absorptiometry (DXA, DEXA) is the most commonly used technique to measure BMD.

Note: For information on central bone density measurements and screening for vertebral fractures using DEXA, please refer to:

Position Statement

Medically Necessary:

Peripheral dual energy x-ray absorptiometry (pDEXA) bone density measurement using the forearm (cortical bone), is considered medically necessary when either of the following criteria is met:

  1. performed for individuals (male or female) with asymptomatic primary hyperparathyroidism (PHPT) where consideration for surgery is in large part determined by bone density level; or
  2. when central (spine or hip) DXA measurements cannot be reliably performed and interpreted (for example: as a result of spinal instrumentation, bilateral hip replacement, or obesity).

Investigational and Not Medically Necessary:

Peripheral dual energy x-ray absorptiometry (pDEXA) bone density studies are considered investigational and not medically necessary for all indications not listed above

Peripheral bone density studies using a method other than dual energy x-ray absorptiometry (pDEXA), are considered investigational and not medically necessary for all indications, including but not limited to, the following methods:

  1. Radiographic absorptiometry of the fingers
  2. Single energy X-ray absorptiometry (SEXA)
  3. Single photon absorptiometry (SPA)
  4. Dual X-ray and laser (DXL)
  5. Ultrasound of the heel.

Peripheral bone density studies are considered investigational and not medically necessary for asymptomatic primary hyperparathyroidism if performed on any part of the body other than the cortical bone (for example, radiographic absorptiometry of the fingers, ultrasound of the heel).

Rationale

Bone Mineral Density Measurements

Bone mineral density (BMD) tests are used to measure the content of calcium and other minerals in the bones. There is currently some controversy over whether central (central hip and spine) or peripheral (for example, forearm, finger and heel) measurements provide superior results. Central measurements are more commonly performed because bone loss most frequently occurs in the spine and hip regions. However, there are some conditions (such as hyperparathyroidism) in which bone loss occurs more rapidly at the peripheral sites and peripheral measurements may therefore be more appropriate. For information regarding central bone density measurements, please refer to CG-MED-39 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry.

Peripheral Bone Mineral Density Measurements

The American Association of Clinical Endocrinologists (AACE) and the American Association of Endocrine Surgeons’ (AAES) position statement on the diagnosis and management of primary hyperparathyroidism indicates that losses of bone mineral density (BMD) from primary hyperparathyroidism (PHPT) are more pronounced in the forearm (cortical bone) than in the spine (trabecular bone) and hip (mixed cortical and trabecular bone) but may occur at all skeletal sites. Although forearm losses of BMD may be more commonly associated with PHPT, the benefit from surgical treatment is more notable for the hip and spine because of the morbidity and mortality associated with fracture. The position statement asserts that individuals with PHPT should undergo DXA scanning of these three sites for reliable documentation of their BMD status as a criterion for recommending parathyroidectomy. For more information regarding bone mineral density measurements of the hip or spine, refer to CG-MED-39 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry.

Chappard and colleagues (2006) studied females with primary hyperparathyroidism and healthy women to assess the bone mineral density (BMD) status in primary hyperparathyroidism (PHPT). Their results suggested that low BMD at lumbar spine and femur is encountered preferentially in premenopausal women. The BMD decrease predominates at limbs in PHPT with presumably a gradient from proximal to distal part of the limbs. Indeed, the distal part of the limbs are the most affected areas in PHPT whatever the amount of cortical or trabecular bone.

The American College of Radiology and Society of Skeletal Radiology practice guideline for the performance of dual-energy x-ray (DXA) recognizes that there may be instances (extensive abdominal aortic calcification, degenerative disease of the lumbar spine or hip, scoliosis, fractures, orthopedic implants), where central DXA measurements are not feasible and alternate sites (the opposite hip, nondominant forearm, or whole body) can be used for evaluating the individual. The guideline also states that “DXA of the nondominant forearm may be useful in individuals who exceed the weight limit of the DXA table and in individuals with hyperparathyroidism” (ACR-SSR, 2013).

Ultrasound Heel Densitometry versus DXA

Because of the slow changes in bone mineral density and the precision of measuring technologies, specifically DXA, monitoring response to therapy prior to 2 years is unlikely to detect changes. In addition, changes in bone mineral density at central sites (for example, hip and spine) are often not reflected by changes in bone mineral density at peripheral sites. Therefore, the use of ultrasound densitometry of the heel is not an effective tool for monitoring response to therapy.

Nayak and colleagues (2006) conducted a meta-analysis to determine the sensitivity and specificity of calcaneal quantitative ultrasound for identifying individuals who meet the World Health Organization's diagnostic criteria for osteoporosis. DXA was used as the reference standard. Of the 1908 articles identified, 25 met the inclusion criteria and calculated the sensitivity and specificity of quantitative ultrasound over a range of thresholds. The authors found that the results of calcaneal quantitative ultrasound at commonly used cutoff thresholds do not definitively exclude or confirm DXA-determined osteoporosis and that additional research is needed before use of this test can be recommended in evidence-based screening programs for osteoporosis.

The 2011 U.S. Preventive Services Task Force (USPSTF) recommendations on screening for osteoporosis state that quantitative ultrasonography seems to be equivalent to DXA for predicting fractures. However, the current diagnostic criteria for osteoporosis utilize DXA measurements as cutoffs, and the measurements obtained from quantitative ultrasonography are not interchangeable with those obtained from DXA. The USPSTF guidelines also point out that trials evaluating drug therapies for osteoporosis use DXA measurements as inclusion criteria. Therefore, in order for quantitative ultrasonography to be relevant and clinically useful, a method for converting or adapting the results of quantitative ultrasonography to the DXA scale needs to developed.

Ultrasound heel densitometry may be shown to have clinical potential as a screening tool for osteoporosis, however, at the present time, data are mixed and do not indicate strong and consistent support for the routine use of ultrasound densitometry as a screening or diagnostic tool or as a means to monitor response to therapy. The full potential of this technology cannot be realized without additional studies on the precision, accuracy, reproducibility, and validity of ultrasound densitometry in the clinical setting.

Background/Overview

Description of Disease

Osteoporosis is a serious public health problem, characterized by slow, prolonged bone loss. The National Osteoporosis Foundation in 2014 noted that in the United States 9.9 million individuals are estimated to have osteoporosis and an additional 33.6 million individuals have low bone density of the hip. About 1 out of every 2 Caucasian females will experience an osteoporosis-related fracture at some point in her lifetime, as will approximately 1 in 5 men. While osteoporosis is less frequent in African Americans, those with osteoporosis have the same elevated fracture risk as Caucasians. These fractures are most common at the hip, spine, and wrist and can result in serious morbidity and in some cases death. The incidence of osteoporosis in the U.S. is expected to increase significantly in the future as the population ages (Cosman, 2014).

Treatment of Disease

The goal of osteoporosis treatment is to prevent or decrease the rate of bone loss. Such treatment may include, but is not necessarily limited to calcium and vitamin supplementations, exercise and medications such as calcitonin, parathyroid hormone, estrogens, bisphosphonates (alendronate, ibandronate and risedronate), and raloxifene. Treatment planning represents a joint decision by the treating physician and the patient (male/female) following discussion of the potential risks and benefits of therapy.

Description of Technology

Bone densitometry is a non-invasive technique that is used to measure bone mineral content in order to predict fracture risks and need for medical therapy. BMD can be measured at several anatomical locations. Peripheral BMD is generally determined by obtaining measurements at the wrist, forearm, finger or heel, while central BMD measurements are obtained from the hip or spine. BMD is typically expressed as the T-score (e.g., the number of standard deviations [SD] below the mean for non-osteopenic, healthy, young women). The World Health Organization defines osteopenia as a T-score of between –1.0 and -2.5 SD, and osteoporosis as a score of –2.5 SD or more.

The following technologies for peripheral measurement of bone mineral content are available:

  1. Dual Energy X-ray Absorptiometry (DXA) for measurement of BMD - DXA (DEXA) is the most commonly used technique to measure BMD because of its ease of use, low radiation exposure, and its ability to measure BMD at both hip and spine. DXA uses two x-ray beams of different energy levels to scan the region of interest and measure the amount of X-rays absorbed by the bone as the beam passes through the body. When DXA is done at peripheral sites such as the forearm, as opposed to more central locations like the hip and spine, it is usually referred to as pDXA.
  2. Quantitative Ultrasonography Scanning (QUS) - Quantitative ultrasonography scanning measures bone mass and strength and assesses bone microarchitecture by detecting the transmission of high-frequency sound waves through bone. QUS results are reported as broadband ultrasound attenuation (BUA) and the speed of sound (SOS). These two parameters are sometimes combined to yield a “stiffness index”. QUS is a technique for measuring bone mass at peripheral sites such as heel, tibia, and phalanges. It does not use ionizing radiation and has the advantage of being small, portable, and relatively inexpensive. However, this technique has not been shown to be useful in monitoring skeletal response to the different therapies used to treat osteoporosis.
  3. Dual-Photon Absorptiometry (DPA) - DPA measures bone mineral content at the spine and hip using photons emitted at low energy levels. It is also used to measure total body calcium and provides a measurement of mineral density in both long bones and bones such as the heel. This method measures the total mineral content in the path of the beam.
  4. Dual X-ray and Laser (DXL) - DXL is a new technique that is presently being researched. It uses two X-ray beams in combination with a laser. The suggestion is that this technique has the advantage of filtering out any influence that adipose tissue inside and outside the bone may have on the accuracy of DXA measurements. DXL has been studied using peripheral sites such as the heel.

The following techniques are less commonly used for bone densitometry:

  1. Single energy x-ray absorptiometry (SEXA);
  2. Single photon absorptiometry (SPA);
  3. Radiographic absorptiometry (RA).
Definitions

Central bone density measurement: An imaging procedure where the density of either the hip or spine is measured using a method that determines bone density by measuring x-rays passing through the bone.

Dual energy x-ray absorptiometry (DXA, DEXA): A test which uses two x-ray beams of different energy levels to scan the region of interest and measure the amount of x-rays absorbed by the bone as the beam passes through the body. When DXA is done at peripheral sites such as the forearm, as opposed to more central locations like the hip and spine, it is usually referred to as pDXA.

pDXA: A bone mineral density study using dual energy x-ray absorptiometry (DXA) to evaluate bone density at peripheral sites (for example, heel or wrist) rather than at central sites such as the hip or spine.

Peripheral bone density studies: Bone density studies using sites other than the hip or spine.

Postmenopausal women: Women who have passed the age of child bearing.

Single energy x-ray absorptiometry (SEXA): This technology uses a different process than DXA or pDXA and is used specifically for the measurement of bone density of peripheral (appendicular) skeletal sites such as the wrist or heel.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT

 

77081

Dual energy x-ray absorptiometry (DXA) bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg., radius, wrist, heel)

 

 

ICD-10 Diagnosis

 

 

All diagnoses

When services are Investigational and Not Medically Necessary:
For the procedure code listed above when criteria are not met or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary:

CPT

 

76977

Ultrasound bone density measurement and interpretation, peripheral site(s), any method

78350

Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry [SPA]

0508T

Pulse-echo ultrasound bone density measurement resulting in indicator of axial bone mineral density, tibia [Bindex®]

 

 

HCPCS

 

G0130

Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel).

 

 

ICD-10 Diagnosis

 

 

All diagnoses

References

Peer Reviewed Publications:

  1. Amin S, Felson DT. Osteoporosis in men. Rheum Dis Clin North Am. 2001; 27(1):19-47.
  2. Blake GM, Fogelman I. Peripheral or central densitometry: does it matter which technique we use? J Clin Densitom. 2001; 4(2):83-96.
  3. Campion JM, Maricic MJ. Osteoporosis in men. Am Fam Physician. 2003; 67(7):1521-1526.
  4. Chappard C, Roux C, et al. Bone status in primary hyperparathyroidism assessed by regional bone mineral density from the whole body scan and QUS imaging at calcaneus. Joint Bone Spine 2006; 73(1):86-94.
  5. Chen T, Chen PJ, Fung CS, et al. Quantitative assessment of osteoporosis from the tibia shaft by ultrasound techniques. Med Eng Phys. 2004; 26(2):141-145.
  6. Cummings SR, Bates D, Black DM. Clinical use of bone densitometry: scientific review. JAMA. 2002; 288(22):1889-1897.
  7. Deal CL. Using bone densitometry to monitor therapy in treating osteoporosis: pros and cons. Curr Rheumatol Rep. 2001; 3(3):233-239.
  8. Gonnelli S, Cepollaro C, Montagnani A, et al. Heel ultrasonography in monitoring alendronate therapy: a four year longitudinal study. Osteoperos Int. 2002; 13(5):415-421.
  9. Harris ST, Watts NB, Genant HK, et al. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. JAMA. 1999; 282(14):1344-1352.
  10. Johnell O, Kanis JA, Oden A, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res. 2005; 20(7):1185-1194.
  11. Jorgensen HL, Warming L, Bjarnason NH, et al. How does quantitative ultrasound compare to dual x-ray absorptiometry at various skeletal sites in relation to the WHO diagnosis categories? Clin Physiol. 2001; 21(1):51-59.
  12. Kanis JA, Borgstrom F, De Laet C, et al. Assessment of fracture risk. Osteoporos Int. 2005; 16(6):581-589.
  13. Kullenberg R, Falch JA. Prevalence of osteoporosis using bone mineral measurements at the calcaneous by dual X-ray and laser (DXL). Osteoporosis Int. 2003; 14(10):823-827.
  14. Miller PD, Zapalowski C, Kulak CA, et al. Bone densitometry: the best way to detect osteoporosis and to monitor therapy. J Clin Endocrinol Metab. 1999; 84(6):1867-1871.
  15. Nairus J, Ahmadi S, Baker S, et al. Quantitative ultrasound: an indicator of osteoporosis in perimenopausal women. J Clin Densitom. 2000; 3(2):141-147.
  16. Nayak S, Olkin I, Liu H, et al. Meta-analysis: accuracy of quantitative ultrasound for identifying patients with osteoporosis. Ann Intern Med. 2006; 144(11):832-841.
  17. Picard D, Brown JP, Rosenthall L, et al. Ability of peripheral DXA measurement to diagnose osteoporosis as assessed by central DXA measurement. J Clin Densitom. 2004; 7(1):111-118.
  18. Stewart A, Reid DM. Precision of quantitative ultrasound: comparison of three commercial scanners. Bone. 2000; 27(1):139-143.
  19. Thomas E, Richardson JC, Irvine A, et al. Osteoporosis: what are the implications of DEXA scanning ‘high risk’ women in primary care? Fam Pract. 2003; 20(3):289-293.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Association of Clinical Endocrinologists (AACE) and American Association of Endocrine Surgeons (AAES) position statement on the diagnosis and management of primary hyperparathyroidism. AACE/AAES Task Force on Primary Hyperparathyroidism. Am J Gastroenterol. 2005; 11(1):49-54.
  2. American Association of Clinical Endocrinologists (AACE). Medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract. 2010; 16(Supl 3):1-37.
  3. American Association of Clinical Endocrinologists (AACE) Medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 Edition, with Selected Updates for 2003. Endocr Pract. 2003; 9(6):544-564.
  4. American College of Obstetrics and Gynecology. Committee opinion No. 270. Bone density screening for osteoporosis. Obs Gynecol. 2002; 99(3):523-525.
  5. American College of Radiology (ACR) Society of Skeletal Radiology (SSR) practice guideline for the performance of dual-energy x-ray absorptiometry (DXA) (Amended 2014). Available at: http://www.acr.org/~/media/EB34DA2F786D4F8E96A70B75EE035992.pdf. Accessed on August 22, 2017.
  6. Blue Cross and Blue Shield Association. Ultrasonography of peripheral sites for selecting patients for pharmacologic treatment for osteoporosis. TEC Assessment, 2002; 17(5).
  7. Centers for Medicare and Medicaid Services. National Coverage Determination for Bone (Mineral) Density Studies. NCD #150.3. Effective July 1, 1998. Available at: http://www.cms.hhs.gov. Accessed on August 22, 2017.
  8. Committee on Practice Bulletins-Gynecology. The American College of Obstetricians and Gynecologists. ACOG Practice Bulletin N. 129. Osteoporosis. Obstet Gynecol. 2012; 120(3):718-734.
  9. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014; 25(10):2359-2381.
  10. Expert Panel on Musculoskeletal Imaging: Ward RJ, Roberts CC, et al. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density. J Am Coll Radiol. 2017; 14(5S):S189-S202.
  11. Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010; 17(1):25-54. Available at: http://www.menopause.org/docs/default-document-library/psosteo10.pdf?sfvrsn=2. Accessed on August 22, 2017.
  12. National Institute of Health (NIH). Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Statement. 2000; 17(1):1-45. Available at http://consensus.nih.gov/2000/2000Osteoporosis111PDF.pdf. Accessed on August 22, 2017.
  13. U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011; 154(5):356-364. Available at: http://annals.org/article.aspx?articleid=746858. Accessed on August 22, 2017.
  14. U.S. Preventive Services Task Force (USPSTF). Screening for osteoporosis in postmenopausal women. a review of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2002; 137(6):529-541. Available at http://www.annals.org/content/137/6/529.full. Accessed on August 22, 2017.
Index

Bone Mineral Density Measurement
Dual-Energy X-Ray Absorptiometry (DXA, DEXA)
Osteoporosis

Document History

Status

Date

Action

  06/28/2018 Updated Coding section with 07/01/2018 CPT changes; added CPT 0508T.

Revised

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.”  Revised position statements to clarify that of the various peripheral bone mineral density measurement methods, only dual energy x-ray absorptiometry (pDEXA) bone density measurement is considered medically necessary when criteria are met. Updated the review date, References and History sections.

Revised

11/03/2016

MPTAC review. In the second bullet of the medically necessary position statement, added the words “for example”. In the investigational and not medically necessary position statement replaced the words “other than asymptomatic primary hyperparathyroidism” with “not listed above”. Updated review date, References and History sections.

Revised

11/05/2015

MPTAC review. Updated review date, References and History sections. Throughout document, changed “e.g.” to “for example”. Removed ICD-9 codes from Coding section.

Reviewed

11/13/2014

MPTAC review. Updated review date, Background/Overview, References and History sections.

Reviewed

11/14/2013

MPTAC review. Updated review date, Rationale, Background/Overview, References and History sections.

Reviewed

02/14/2013

MPTAC review. Updated review date, References and History sections of the document.

Revised

02/16/2012

MPTAC review. Revised the medically necessary criteria to include peripheral bone density measurement using the forearm (cortical bone) when central (spine or hip) DXA measurements cannot be reliably performed and interpreted as a result of spinal instrumentation, bilateral hip replacement, or obesity. Updated review date, Rationale, Coding, References and History sections of the document.

Reviewed

11/17/2011

MPTAC review. Updated review date, References and History section of the document. Updated Coding section; removed 77079, 77083 deleted 12/31/2011.

Reviewed

11/18/2010

MPTAC review. Updated review date, Rationale, References and History sections of the document.

Reviewed

11/19/2009

MPTAC review. Updated review date, Definitions, Coding, History and References sections of the document.

Revised

11/20/2008

MPTAC review. Screening of vertebral fractures using DEXA removed from this document and addressed in CG-RAD-18 - Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry. Title changed to Peripheral Bone Mineral Density Measurement. Updated rationale, Background/Overview, Coding, References and History sections.

Revised

11/29/2007

MPTAC review. Added statement to clarify that peripheral BMD studies for asymptomatic primary hyperparathyroidism are considered investigational and not medically necessary if performed on any part of the body other than the cortical bone. Updated review date, Rationale, Background/Overview, History and References sections of the document. The phrase “investigational/not medically necessary” was clarified to read “investigational and not medically necessary.”

Reviewed

08/23/2007

MPTAC review. Updated the Discussion/General Information section of the document to reflect language added to the Discussion/General Information section of CG-RAD-18 Central (Hip Or Spine) Bone Density Measurement.

 

01/01/2007

Updated coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 76070, 76071, 76075, 76076, 76077, 76078 deleted 12/31/2006.

Revised

12/07/2006

MPTAC revision. Document revised to only address peripheral bone density measurement and screening of vertebral fractures using DEXA. Central bone density measurement now addressed in CG-RAD-18 Central (Hip Or Spine) Bone Density Measurement. Coding, History and References updated.

Reviewed

06/08/2006

MPTAC review. Review date, Coding and References updated.

 

11/17/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Revised

07/14/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

04/28/2005

RAD.00004

Bone Density Studies

WellPoint Health Networks, Inc.

04/28/2005

2.07.02

Bone Mineral Density Measurement (Adults)

WellPoint Health Networks, Inc.

04/28/2005

4.07.01

Screening for Vertebral Fractures Using Dual X-ray Absorptiometry